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Food Fortification in Public Health Policy

Food Fortification in Public Health Policy. TH Tulchinsky MD MPH Braun SPH 11 Nov 2003. Essential Considerations. Public health and medical responsibility Food industry and regulators involved Create demand - enriched foods, behavior changes Monitor compliance and ID rates

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Food Fortification in Public Health Policy

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  1. Food Fortification in Public Health Policy TH Tulchinsky MD MPH Braun SPH 11 Nov 2003

  2. Essential Considerations • Public health and medical responsibility • Food industry and regulators involved • Create demand - enriched foods, behavior changes • Monitor compliance and ID rates • National council on nutrition - academic and professional organizations and public reps • Long term program • Regulatory, monitoring and laboratory support

  3. Public Health Nutrition Strategies • Food based strategy • Socio economic factors • Food supply/costs • Education • Supplementation for target groups • Women and children • Elderly • Fortification of basic foods • Surveillance and monitoring

  4. 18-19th Century Breakthroughs • Lind and scurvy 1747 • Lemon juice in Royal Navy, 1796 • Davy isolates sodium, potassium, calcium, magnesium, sulphur, boron, 1807 • Chatin shows iodine prevents goiter, 1850 • Takaki and beriberi, Japanese Navy, 1885 • Eijkman publishes cause of beriberi, 1897

  5. Low Cost Solutions to Eliminate Micronutrient Malnutrition 4 3 Annual Per Capita Cost of Interventions 2 US Dollars 1 0 Iron Iron Fort . Iodine Iodine Vit A Vit A Suppl . Suppl . Fort . Suppl . Fort . Source: World Bank, 1994

  6. Relative Cost Effectiveness of Micronutrient Interventions Productivity Gained per US$ Expended $ 146 . 0 $ 150 $ 125 $ 100 $ 84 . 1 $ 75 $ 47 . 5 $ 50 $ 28 . 0 $ 24 . 7 $ 13 . 8 $ 25 $ 0 Fe Suppl . Fe Suppl . Iodine Vit . A Fe Fort . Vit . A ( Wom .) ( Preg . Fort . Fort . Suppl . Wom .) Source: UNICEF/UNU/WHO/MI, 1999

  7. Vital Amines • 1900, nutrition - calories, fats, carbohydrates proteins • 1912, Funk defines vital amines • Rickets, scurvy, goiter, beriberi common in industrial countries • Pellagra “epidemic” in southern US • 1914, Goldberger of USPHS investigates pellagra • 1922, McCollum and vitamin D in cod liver oil

  8. More on Vitamins • 1931, Fluoride shown to prevent tooth decay • 1932, Vitamin C and riboflavin isolated • 1933, Williams - kwashiorkor as vitamin deficiency • 1941, Prenatal diet and health of newborn • 1945, Fluoridation of water Grand Rapids • 1948, Vitamin B12 isolated • 1949, Framingham study begins

  9. Key Landmarks • Morton’s iodized salt, 1924 • Louisiana - mandates vit B fortification of flour, 1928 • US federal mandate - enrichment of flour with vitamins B and iron, 1941 • UK and colonies same during WWII

  10. Preventing Goiter and Iodine Deficiency Disorders • 1917, high % US draftees rejected - goiter • 1922-27, goiter rates fall from 39% to 9% by statewide prevention programs • 1924, Morton’s Iodized Salt (N America) • 1979, Iodization mandatory in Canada • 1980s, WHO - universal iodization of salt • Many countries achieved iodization

  11. Iodine Fortification of Salt in the U.S.: Trend in Goiter Prevalence in Michigan WHO Monograph Series N. 44

  12. Pellagra: The 4 Ds • Diarrhea, dermatitis, dementia, death • Thought to be of infectious origin • Common in prisons, mental institutions, sharecroppers in southern US • Curable by dietary change (Goldberger) • 1929, niacin found as essential factor • 1906-1940, 3 million cases and 100,000 deaths attributed to pellagra

  13. Figure 2

  14. Rickets • 1921, rickets affects 75% of children in New York City schools • Cod liver oil commonly used (middle class) • 1940s, US fortifies milk with vitamin D dramatically reduces rickets incidence • Canada fortifies milk 1940s, then refortifies resulting in increase in rickets in 1960s

  15. Global Burden of Micronutrient Deficiencies • Iron deficiency - all ages • Chronic undernutrition – all ages • Iodine deficiency – pregnancy • Vitamin A deficiency – young children • PEM – young children • Folic acid deficiency – all ages • 2 billion* • 1 billion* • 200 million** • 200 million* • 167 million* • Unknown • Source WHO

  16. Iron Deficiency • Commonest MND • Affects survival, health and productivity • Affects women in age of fertility • Affects pregnancy and newborn • Affects growth and cognitive development of infants and children • Interaction with vitamin C deficiency

  17. Global Burden of Iron Deficiency • Source WHO

  18. Benefits of PreventingIron Deficiency • Benefits to children • Improved behavioral and cognitive development • Improved child survival (where severe anemia is common) • Benefits to adolescents • Improved cognitive performance • Better iron stores for later pregnancies (females)

  19. Benefits to Pregnant Women and Their Infants • Decreased low birth weight and perinatal mortality • Decreased maternal mortality and obstetrical complications (where severe anemia is common) • Benefits to all Individuals • Improved fitness and work capacity • Improved cognition • Increased immunity • Lower morbidity from infectious disease

  20. Trends in Prevalence of Anemia* in Low-income U.S. Children, 12-17 Months Old *Hgb <10.3 g/dL Yip et al., JAMA, 1987

  21. Preschool children • School age children and adolescents • Non-pregnant women • Pregnant women • Adult men

  22. Prevalence of iron deficiency* by income and race/ethnicity, U.S., 1-4 year olds, 1988-94 *Based on serum ferritin model NHANES III (Ogden et al., 1998)

  23. US Federal Policy • USDA extension programs • 1921-29, US Maternal and Infancy Act - state health departments employ nutritionists • 1930s, relief/commodity distribution • 1941, enriched wheat flour with iron, vit B • 1941, US establishes RDAs • Food stamps, WIC, school lunch programs • National nutrition surveys

  24. Canada 1979 • National nutrition survey 1971 • Geographic, social and ethnic deficiencies • Process of consultation • 1979 federal regulations, mandatory • Vitamin A and D in all milk products • Iodine in salt • Vitamins B and iron in flour

  25. Epidemiologic Revolution 1960s-1980s • Risk factors for chronic disease • Health field concept • Health for All • Declining mortality from stroke and CHD, trauma • Advances in drugs and diagnostics • Control of infectious diseases • Rapid increase in costs of care: health system reform

  26. Nutrition Interactions • Iodine Deficiency – psychomotor retardation • Iron Def Anemia and infectious diseases • Iron promotes growth and development • Vitamin A and infectious diseases e.g. measles • Vitamin A promotes growth • Folic acid prevents birth defects • Folic acid with CVD, Alzheimer’s Disease • Nutrition and cancer • Nutrition and cardiovascular disease • Nutrition and diabetes • Nutrition in disease management

  27. Folic Acid and NTDs • Pre pregnancy folic acid supplements prevent neural tube defects, 1980s • Supplements to women in age of fertility achieves <1/3 coverage, 1990s (US) • FDA mandates fortification of “enriched” flour, from 1998 • Canada and UK also mandate folic acid fortification of flour • New paradigm in public health

  28. Table Return to top.Figure

  29. Figure

  30. Folic Acid and Heart Disease • High homocysteine levels associated with excess CHD, birth defects, Alzheimer’s Disease • Folic acid reduces high homocysteine • Flour fortification effective in raising FA levels in population • Clinical trials of folic acid and CHD underway • New paradigm in public health nutrition

  31. Osteoporosis • Aging of the population • Vit D production in skin seasonal • Sun varies by season and latitude even in sunny countries • Fortification of calcium popularized • Vitamin D lacking in raw milk • Calcium, vitamin D, fluoride co-factors • Fortifying milk products with Vit D needed

  32. Problems with Fortification Policy • Antagonism to trends in North America • European resistance e.g. EU • Nutritionist focus on clinical approach • WHO ambivalence/opposition • “Green” attitudes • Medical attitudes and lack of interest • Resistance to “mandatory medication” • Individual choice • Clinical vs. population approaches • Manufacturer’s and regulatory agency attitudes

  33. Progress • Decreased contamination and food-borne disease • Improved food handling methods - refrigeration • Improved nutritional value of foods and crops • Food fortification • Identifying essential micronutrients • Food-fortification programs eliminated rickets, goiter, pellagra in the US, Canada • Folic acid and other new disease relationships • Micronutrients as functional food elements • Genetically engineered foods

  34. Conclusion • Nutrition a major public health issue • Affects MCH, infectious, non infectious disease • High priority – birth defects, IDA, IDD, CHD • Fortification has low sex appeal vs. clinical • Mandatory vs. voluntary – false dilemma • Requires concern, knowledge, advocacy and leadership • Public health role

  35. Referents • World Health Organization • UNICEF • CDC • American Academy of Pediatrics • American College Obstetrics and Gynecology • Food and Drug Administration • Health Canada

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